The Practice and Experience of Significant
Event Audit in Primary Care

Grace Sweeney, Richard Westcott &
Jonathan Stead

Aims

The aim of the study was to explore the use of SEA within
primary care teams, and to identify the potential benefits afforded by the
process in terms of team-building, professional development and service outcome.
The project was funded by the Somerset & North Devon Education Purchasing
Consortium

Study Design and Method

This was a longitudinal study, following a
case study approach and using qualitative methods of data collection and
analysis. Initially, we conducted preliminary interviews with twelve members of
the primary care team. These individuals included practice managers, general
practitioners, practice nurses, receptionists and community staff, and were
recruited from three separate practices where SEA had been established as a
regular activity. Following completion of the preliminary interviews, two
practices were recruited for the purposes of more detailed examination of the
implementation and development of SEA. Both of these practices were selected as
they were in the process of developing SEA as a regular event in practice life.
Data was collected at each of the two primary care sites by (1) observing six
consecutive SEA meetings, and (2) interviewing a sample of the multidisciplinary
team prior to and following the observed SEA meetings. Each of the SEA meetings
were observed by the same researcher, who assumed the role of a non-participant
observer, and who kept a written record of the proceedings. These field notes
were supplemented by official agendas and minutes arising from each meeting.
Data arising from the observation arm of the study was subject to a content
analysis. Pre-SEA and post-SEA interviews were semi-structured, tape-recorded
and subjected to a grounded theory analysis.

At the end of data collection and data analysis, a
'negotiated feedback session' was convened in both primary care practices, so
that findings of the study could be shared with and verified by, study
participants.

Main Findings

This study has now been completed. The findings of the
preliminary interviews have been published as a separate piece of work (Westcott,
Sweeney, & Stead, 2000), and each of the case studies are in the process of
being prepared for publication. The following points can be distilled from the
combined findings of the case study practices;

* SEA was viewed as a positive development in each
practice - the meetings were perceived as leading to a more egalitarian and
more supportive working environment. It was recognised that a shift in
culture from a hierarchal to a more democratic setting would require a
considerable investment of trust by all team members, but the majority of
participants felt that SEA was a development in the 'right direction'.

* SEA lead to real changes in the practices - the most
significant changes were related to day-to-day issues which were relatively
easy to solve but which made life easier for members of the team.

* Leadership of the SEA meetings was seen to be the
linchpin of the whole process - the leader needed to be respected by all
members of the team, to be approachable for all members, to provide order
and structure to the meetings, to develop a feeling of safety within the
meetings and to oversee the whole process of SEA.

* The process of SEA should itself be 'managed' with
official agendas and minutes for each meeting, ensuring that solutions
reached are followed up, providing support (and possibly debriefing) for
team members after emotionally-charged meetings, and establishing regular
reviews of the process.

* Sensitive selection of items for discussion at the
meetings was considered very important. There needed to be a balance of
clinical and administrative items for discussion, and team members were
aware that items should be vetted for appropriateness prior to being placed
on the agenda. In addition there was a strong consensus that no item should
be discussed at a meeting if the 'key player(s)' were not present.

* Some individuals remained concerned about various
aspects of the meetings. In particular, these were related to
confidentiality of items discussed, concerns about the potentially divisive
nature of the meetings ('performing a witch hunt' and 'opening Pandora's
box'), and of the amount of extra work generated by the meetings.

* There was a feeling that the leader should provide
more feedback on the solutions which have been achieved and that more
positive items (leading to congratulation of team members) should be put on
the agenda.

Conclusions

The use of SEA in primary care was generally viewed as a
positive development by all members of the team. There was evidence from both
practices that the identification of items through the process of SEA lead to
swift and positive change in practice life. In addition there was seen to be a
considerable improvement in team relations and in the general ethos of the
participating practices.